Thanks, Amit
but isn't the key issue the lack of time- the most precious commodity  
of our times? I certainly am capable of taking care of uncomplicated  
diabetes, COPD, hypertension etc but I stick to hem-onc problems since  
I don't have time to look up the latest recommendation and hence I end  
up referring the patient. If I have more time I would be able to solve  
more than 1-2 patient's problem, which is what typically a  
subspecialist tend to manage. A friend of mine suggested that a  
solution for contemprary fragmentation of care is to limit the number  
of patients per physician (akin to what was done for doctors in  
training). A too radical idea? But, it raises the important question :  
would patients be better served with one doctor (who has enough time)  
taking care of their multiple problems, or multilple subspecialists?  
( I am not talking about one time consults/procedures; I am referring  
to management of chronic problems). And, I am looking forward to  
seeing how the integrated systems that Jim and Rakesh mentioned will  
work in practice- at the moment the system is all about managing time/  
work flow and less about providing the best care).
Ben





On Aug 31, 2009, at 8:49 AM, "Ghosh, Amit K., M.D."  
<[log in to unmask]> wrote:

> Dear Ben,
> The ABMS/ ABIM exam system tests for knowledge not skills. Even if  
> they
> measured skills they would have to limit to one or few areas that can
> never match the complexity of clinical practice.
> One specialty that got into trouble because of the proliferation of
> information, unrealistic expectation and constant scrutiny is Gen.
> Medicine. This has resulted in shrinking interest and enrollment by
> medical students for Gen. Med ( despite visions of Oslerian
> professionalism and bed side skills)  and exodus to other areas by
> individuals trained in Gen. Medicine. Shrinking pay scale, diminishing
> respect by other subspecialty and insurmountable pressures by public  
> and
> press are also close contributors. By the way this group of physicians
> are superbly trained to dissect any article and are often the trainers
> in any EBM sessions/ workshops. This is not EBM's problem though.
> Several of these issues could not be foreseen.
> Hence, just because you know to read an article doesn't mean you will
> not get a consult. There more on the plate than critical appraisal and
> filling the blanks of an EBM worksheet. It might be considered  
> quixotic
> in a way to just read an article and acting out on your own. EBM  
> however
> does make someone catch up to any new thing rapidly, the application  
> of
> the article effectively however needs another 3-5 years of training.
> Amit Ghosh
> Mayo Clinic, Rochester
>
>
> -----Original Message-----
> From: Evidence based health (EBH)
> [mailto:[log in to unmask]] On Behalf Of  
> Djulbegovic,
> Benjamin
> Sent: Monday, August 31, 2009 7:20 AM
> To: [log in to unmask]
> Subject: Re: EBM and increasing requests for the use of consultants...
>
> No doubt what you described is likely one of the reasons for  
> increasing
> use of referrals. However, our (educational) organizational  
> structure is
> such that we are still insisting on individual physicians proficiency
> (e.g. typically in the US you need at least 30-50 annual CME, take  
> your
> specialty exam every 7-10 years depending on your specialty etc). So,
> tremendous effort goes into building your individual knowledge base in
> order to refer your patient to a number of other consultants?
> ben
>
>
> -----Original Message-----
> From: Piersante Sestini [mailto:[log in to unmask]]
> Sent: Monday, August 31, 2009 2:41 AM
> To: Djulbegovic, Benjamin
> Cc: [log in to unmask]
> Subject: Re: EBM and increasing requests for the use of consultants...
>
> I am not sure whether the number of referrals did increase in Italy  
> over
> the last 10 years, but they certainly did enormously over the last  
> 20 or
> 30 years.
> As you suggests, this has more to do with the way the health industry
> works that with the availability of systematic reviews and guidelines.
> Medicine is less and less seen as an individual business and more as a
> collective, interprofessional teamwork.
> The reason is probably the same that lead to the success of EBM: the
> enormous increase in information to be managed and of needed skills.
>
> If a physician has to care for many patients with a large variety of
> possible disorders, she cannot get enough expertise on most of them to
> be confident to treat them, even if she has the time of reading some
> relevant guidelines: you don't get skills by reading a guideline. Of
> course, no conscientious physician would treat a patient just based  
> on a
> quick browsing through a guideline and a few checklists, without  
> having
> a good confidence of her skills and understanding of the underlying
> condition.
>
> Thus, IMHO guidelines are more likely to be useful to improve the
> practice of different teams, than to be used by every single physician
> of each team.
>
> regards,
> Piersante Sestini
>
>
>
>
>
>
> Djulbegovic, Benjamin wrote:
>>
>> Dear all
>>
>> It has been my impression that the rise of EBM (along with
>> proliferation of systematic reviews (SR) and guidelines, critical
>> attitudes toward health care claims etc) has not reduced the requests
>> for the use of experts (consultants). Paradoxically, the last decade
>> has seen ever increasing use of consultants. In the US, at least, an
>> explanation for this trend in ever increasing requests for "consults"
>> is related to the incentives to see more and more patients with the
>> consequence that doctors do not have time to look up the guidelines,
>> SRs etc. As a result, doctors just ask for yet another consult. I
>> wonder what has been trend in other countries? Do physicians  
>> elsewhere
>> also consult more often than, say, 10 years ago? If yes, why is this
>> so? What is the purpose of developing all these guidelines if only
>> experts will use them (and who will typically deviate from the
>> guidelines)? What is an average number of physicians that the  
>> patients
>> typically see?
>>
>> I would appreciate some thoughts on this issue, which is actually not
>> a trivial one as it may appear on the first blush.
>>
>> Thanks
>>
>> ben
>>
>> Benjamin Djulbegovic, MD, PhD
>>
>> Professor of Medicine and Oncology
>>